Avoiding Never Events Damian Cottle

Team Resource Management TRM Team Resource Management

TRM Team Resource Management Introduced by NASA in the 1980’s Originally called Cockpit Resource Management

Team Resource Management TRM Team Resource Management Communication Decision making Incident Reporting

Communication

Tenerife March 27th 1977 KLM 4805 -Boeing 747, 248 onboard Pan Am 1736 - Boeing 747, 396 onboard

All 248 aboard KLM flight died

All 248 aboard KLM flight died 335 of 396 aboard Pan Am died

All 248 aboard KLM flight died 335 of 396 aboard Pan Am died Total dead 583

The deadliest accident in aviation history All 248 aboard KLM flight died 335 of 396 aboard Pan Am died Total dead 583 The deadliest accident in aviation history

Communication

Communication To foster a less authoritarian culture whilst retaining a command hierarchy

Communication To foster a less authoritarian culture whilst retaining a command hierarchy Management Team Leader Team members

Communication To foster a less authoritarian culture whilst retaining a command hierarchy Management Training Team Leader Team members

Communication To foster a less authoritarian culture whilst retaining a command hierarchy Management Training Team Leader Set an inclusive tone Team members

Communication To foster a less authoritarian culture whilst retaining a command hierarchy Management Training Team Leader Set an inclusive tone Team members Active participation

Team Resource Management TRM Team Resource Management Communication Decision making Incident Reporting

Decision Making

UA173 28th Dec 1978 New York to Portland

189 on board 10 Dead 24 injured

Decision Making

Decision Making

Decision Making Brief Aims Threats Maintenance Normal Checklist

Decision Making Early intervention Communication Non-normal Checklist

Decision Making Memory Actions Non- normal Checklist TDODAR

T D O D A R

Time D O D A R

Time Diagnose O D A R

Time Diagnose Options D A R

Time Diagnose Options Decide A R

Time Diagnose Options Decide Allocate R

Time Diagnose Options Decide Allocate Review

Team Resource Management TRM Team Resource Management Communication Decision making Incident Reporting

Incident Reporting

BEA 548 18th June 1972 London to Brussels

Worst loss of life in British aviation history 118 dead Worst loss of life in British aviation history

Incident Reporting

Clear channels for reporting Encouraging Reports No Blame Culture Clear channels for reporting

Effective Reporting Team Debrief Learning Points

Learning from Reports Data analysis Focused development

Team Resource Management TRM Team Resource Management Communication Decision making Incident Reporting

Avoiding Never Events